|
Medical Policy: 07.01.41
Original Effective Date: May 2008
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Pulsed radiofrequency has been used as a non- or minimally destructive technique alternative to radiofrequency heat lesions in the treatment of a variety of pain syndromes. During pulsed radiofrequency, 20-50 msec pulses of current are delivered at a rate of 2 per second at temperatures of 45 degrees C or lower. The pauses between pulses allow heat to dissipate and prevent formation of thermal lesions. This, in effect, stuns the nerve tissue rather than destroys it. The mechanism for pain relief is not well understood; it has been hypothesized that the effect has not been due to the production of heat, but to exposure to electrical fields.
The American Society of Interventional Pain Physicians (ASIPP) practice guideline, Interventional Techniques in the Management of Chronic Spinal Pain, states that utilizing traditional radiofrequency neurotomy techniques in the cervical and lumbar regions, the evidence for radiofrequency neurotomy of medial branches is strong for short-term and moderate for long-term relief. The evidence for pulsed radiofrequency for this indication is indeterminate. The evidence for thermal and pulsed radiofrequency of the SI joint is limited.
 Top
Prior Approval:
Not applicable
Top
Policy:
Pulsed radiofrequency is considered investigational in the treatment of various pain syndromes including but not limited to, headache, neck pain, discogenic pain, low back pain, zygapophyseal joint pain, facet and sacroiliac joint dysfunction, and complex regional pain syndrome. There is insufficient evidence in the published medical literature to demonstrate efficacy and duration of effect.
Top
Procedure Codes and Billing Guidelines:
-
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
-
CPT 64999 Unlisted procedure, nervous system
Top
Selected References:
-
Cahana A, Van Zundert J, Macrea L et al. Pulsed radiofrequency: current clinical and biological literature available. Pain Med. 2006 Sep-Oct;7(5):411-23.
-
Lindner R, Sluijter ME, Schleinzer W. Pulsed radiofrequency treatment of the lumbar medial branch for facet pain: a retrospective analysis. Pain Med. 2006 Sep-Oct;7(5):435-9.
-
Tekin I, Mirzai H, Ok G et al. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin J Pain. 2007 Jul-Aug;23(6):524-9.
-
Van Zundert J, Patijun J, Kessels A et al. Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized trial. Pain. 2007 Jan;127(1-2):173-82. Comment in: Expert Rev Neurother. 2007 May;7(5):471-2. Pain. 2007 Jan;127(1-2):3-4.
-
Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111.
-
Simopolous TT, Kraemer J, Nagda JV et al. Response to pulsed and continuous radiofrequency lesioning of the dorsal root ganglion and segmental nerves in patients with chronic lumbar radicular pain. Pain Physician. 2008 Mar;11(2):137-44.
-
Van Boxem K, van Bilsen J, de Meij N et al. Pulsed radiofrequency treatment adjacent to the lumbar dorsal root ganglion for the management of lumbosacral radicular syndrome: a clinical audit. Pain Med. 2011 Aug 3. doi:10.1111/j.1526-4637.2011.01202.x. [Epub ahead of print].
-
Nagda JV, Davis CW, Bajwa ZH et al. Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain. Pain Physician. 2011 Jul-Aug; 14(4):371-6.
-
Todorov L. Pulsed radiofrequency of the sural nerve for the treatment of chronic ankle pain. Pain Physician. 2011 May-Jun; 14(3):301-4.
-
Korkmaz OK, Capaci K, Eyigor C et al. Pulsed radiofrequency versus conventional transcutaneous electrical nerve stimulation in painful shoulder: a prospective, randomized study. Clin Rehabil. 2010 Nov; 24(11):1000-8. Epub 2010 Aug 4.
-
Taverner MG, Ward TL, Loughnan TE. Transcutaneous pulsed radiofrequency treatment in patients with painful knee awaiting total knee joint replacement. Clin J Pain. 2010 Jun;26(5):429-32.
-
Eyigor C, Eyigor S, Korkmaz OK et al. Intra-articular corticosteroid injections versus pulsed radiofrequency in painful shoulder: a prospective, randomized, single-blinded study. Clin J Pain. 2010 Jun;26(5):386-92.
-
Vanelderen P, Rouwette T, De Vooght P et al. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up. Reg Anesth Pain Med. 2010 Mar-Apr; 35(2):148-51.
Top
Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
